NCG120085_DOSA Form_20221222

e NC Department of Environmental Quality
Division of Energy, Mineral and Land Resources
Enrlronmmlal Qualify
Stormwater Permit Delegation of Signature Authority Form
Directions are in red
This form shall be used to delegate signature authority from the permit Owner (Permittee) to
another party. Only the Responsible Official defined below may submit permit applications and
reports required by the permit (such as Data Monitoring Reports and Annual Reports) until this
form is completed and submitted to the DEMLR Stormwater Program. Please note that delegating
signature authority does not relieve the Permit Owner from the responsibility for permit
compliance.
The permit Owner is the legal entity to whichywhom a permit has been issued, and may be an individual
or an organization such as a company or government agency. Every Owner is required to have a
Responsible Official who meets the legal signature authority requirements in 40 CFR 122.22 summarized
below.'
• For a corporation, the Responsible Official shall be a president, secretary, treasurer, or vice-
president in charge of a principal business function, or another individual who performs similar
functions for the corporation, or the manager of one or more manufacturing, production, or operating
facilities who is authorized to make management decisions about the facility operation.
• For a partnership or sole proprietorship, the Responsible Official shall be a general partner or the
proprietor, respectively; or
• For a municipality, State, Federal, or other public agency, the Responsible Official shall be either a
principal executive officer [CitylCounty Manager] or ranking elected official [Mayor].
Even if delegated signatory authority has been delegated to another individual, the Responsible Official
retains responsibility for compliance with permit conditions.
Organization Name:
Union County Government
Responsible Official Name:
Brian Matthews
Responsible Official Title:
Interim County Manager
Email Address:
[e-mail]
Phone:
704-283-3636
Mailing Address:
500 N. Main Street., Suite 913
City:
Monroe
I State:
NC
I Zip:
28112
Stormwater Delegation of Signature Authority Form
Page 1

A. Persons to Receive Signatory Authority
=> The signatures of the persons listed below indicates their acceptance of signatory authority.
Delegated Party Name:
Caleb Sinclair
Delegated Party Title:
Said waste Director
Permit Number:
NCG120085
Email Address:
[e-mail]
I Phone:
704283-3576
Mailing Address:
500 North Main Street.
City:
Mo
I State:
INC
I Zip:
128112
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
/L IZI 17-
Delegated Party Name:
Delegated Party Title:
Permit Number:
Email Address:
Phone:
Mailing Address:
City:
State:
Zip:
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Delegated Party Name:
Delegated Party Title:
Permit Number.
Email Address:
Phone:
Mailing Address:
City:
State:
Zip:
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Delegated Party Name:
Delegated Party Title:
Permit Number:
Email Address:
Phone:
Mailing Address:
City:
State:
Zip:
Signature of Delegated Party indicating
acceptance of Signatory Authority:
i Date:
Stormwater Permit Delegation of Signatory Authority Form
Page 2

B. Responsible Official Signature
The Responsible Official, as identified in accordance with 40 CFR 122.22, is the appropriate
individual with the authority to sign and submit reports for the organization.
As the Responsible Official, I, Brian W. Matthews
have the authority to enter into this Agreement for
Union County Government
(Owner/Organization Name).
(printed name),
I request that the DEMLR Stormwater Program include the persons listed in Part A of this form
signatory authority for the above -named permit.
I acknowledge that I, and the persons listed in Part A of this form work at/for my organization
and have authority to act as a signatory for purposes of the NCDEQ's electronic document
systems.
By submitting this application, I, Brian W. Matthews (printed name),
have read, understand, and accept the terms and conditions of the stormwater permit(s) for
which I am the Responsible Official.
W
Official Signature
Interim County Manager 12120/2022
Title Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3

NC Division of Energy, Mineral and Land Resources
NPDES Stormwater Permit Summary
NC DEMLR has the following information in our Permit Database for your penniI as o112/152022.
Permit Number: NCG120085 Permit Status: Active
Permit Type: Landfill Stormwater Discharge COC
Facility Name: Union County Solid Waste Mgmt. Facility (C & D Landfilll
Facility Addressl: 2125 Austin Chaney Rd
Facility Address2:
City, State & Zip: Wingate NC 28174
Owner Information Details:
MUST submit a Change ofNeme/Ownership form to DEMLR to make any changes to this Owner information.
(Click Here for "Change of Name/Ownership"Form)
Owner Name: Union County
Owner Type: Government - County Owner Type Group: Organization
*** Legally Responsible for Permit ***
(Responsible corporate officer/principle executive officer or ranking elected official/general partner or proprietor;
or any other person with delegated signatory authority from the legally responsible person.)
Owner Affiliation: Brian Matthews
Addressi: 500 N Main St Ste 70
Address2:
City, State & Zip:
Work Phone:
Email Address:
Monroe. NC 28112
704-383-3636
Title: Interim County Manager
Fax:
*** Permit Annual Fee Billing ***
Billing Month: January
Invoice Number Invoice Date Invoice Due Date Invoice Amount Invoice Status
2022PR012123 1212,12022 1/1/2023 $100.00 Open
Owner Contact Person(s)
Contact Name Title Address Phone Fax Email
Facility Contact Person(s)
Contact Name Title Address Phone Fax Email
Chris Medlin 2125 Austin Chaney Rd, Wingate, NC 704-989-1949 704-233-0255 chrismedlin@unionc
28174 ountync.gov
Permit Contact Pt
Contact Name Title
Address
rx-r-74111007 rVENNEENFrIm
p3q- 1

NC Division of Energy, Mineral and Land Resources
NPDES Stormwater Permit Summary
NC DEMLR has the following information in our Permit Database for your permit as of 12/15/2022.
Outfall #: 006 Outfall Description: Richardson Creek
Outfall Lattitude: 035 33330 Outfall Longitude:-80,461110 Represented by Outfall:
% Stormwater: 100 % Industrial:
Basin
Yadkin
Waterbody Name
Richardson Creek
Outfall #: 007 Outfall Description: Richardson Creek
Outfall Lattitude: 35.031940 Outfall Longitude:-80,464440
% Stormwater: 100 % Industrial:
Basin
Yadkin
Waterbody Name
Richardson Creek
Outfall #: 008 Outfall Description: Richardson Creek
Outfall Lattitude: 35.035560 Outfall Longitude:-80,468330
% Stormwater: 100 % Industrial:
Basin
Yadkin
Stream
Index Number
13-17-36-(5)
Waterbody
Classification
C
Represented by Outfall:
Stream
Index Number
13-17-36-(5)
Waterbody
Classification
C
Represented by Outfall:
Stream Waterbody
Waterbody Name Index Number Classification
Richardson Creek 13-17-36-(5) C
P;rj., -:

NC Division of Energy, Mineral and Land Resources
NPDES Stormwater Permit Summary
NC DEMLR has the followine information in our Permit Database for your aermit as of 12/15/2022.
Outfall #: 001 Outfall Description: Richardson Creek
Outfall Lattitude: 35.039170 Outfall Longitude:-80,458060
Stormwater: 100 % Industrial:
Basin Waterbody Name
Yadkin Richardson Creek
Outfall #: 002 Outfall Description: Richardson Creek
Outfall Lattitude: 35,039440 Outfall Longitude:-80,459720
Stormwater: 100 "/o Industrial:
Basin
Yadkin
Waterbody Name
Richardson Creek
Outfall #: 003 Outfall Description: Richardson Creek
Outfall Lattitude: 35.038890 Outfall Longitude:-80,460000
Stormwater: 100 % Industrial:
Basin
Yadkin
Waterbody Name
Richardson Creek
Outfall #: 004 Outfall Description: Richardson Creek
Outfall Lattitude: 35.037220 Outfall Longitude:-80.462500
Stormwater: 100 % Industrial:
Basin
Yadkin
Waterbody Name
Richardson Creek
Outfall #: 005 Outfall Description: Richardson Creek
Outfall Lattitude: 35.037780 Outfall Longitude:-80,465280
Stormwater: 100 % Industrial:
Basin
Yadkin
Represented by Outfall:
Stream
Index Number
13-17-36-(5)
Waterbody
Classification
C
Represented by Outfall:
Stream
Index Number
13-17-36-(5)
Waterbody
Classification
C
Represented by Outfall:
Stream
Index Number
13-17-36-(5)
Waterbody
Classification
C
Represented by Outfall:
Stream
Index Number
13-17-36-(5)
Waterbody
Classification
C
Represented by Outfall:
Stream Waterbody
Waterbody Name Index Number Classification
Richardson Creek 13-17-36-(5) C

NC Division of Energy, Mineral and Land Resources
NPDES Stormwater Permit Summary
NC DEiNILR has the following information in our Permit Database for your permit as of 12/15/2022.
Permit Billing Contact(s)
Contact Name Title Address Phone Fax Email
Chris Medlin 500 N Main St, Ste 500, Monroe, NC 704-989-1949 chrismedlin@unionc
28112-4804 ountync.gov
Person(s) with Delegated Signatory Authority
Type Contact Name Title Address Phone Em Kann
Owner Crystal Panico 500 N Main St Ste 400, 704-296-4239 704-296-4232 crystal.panico@unionco
Monroe, NC 28112 nc.aov
Person(s) with Electronic Signature Authority
Type Contact Name Title Address Phone Fax Email
Outfalls
Pa�j> 2